Step by Step Guide to Reducing from Benzodiazepines

Home , Alprazolam, Heather Ashton

STEP BY STEP GUIDE

Reducing from Benzodiazepines & Recovery from Withdrawal

Table of Contents

Introduction ...... 3

List of Benzodiazepines ...... 5

Dose Equivalents ...... 6

Stabilising and Reducing the Dose ...... 7

Example of a Reduction Regime ...... 11

Benzodiazepine Withdrawal Symptoms ...... 13

Management of Withdrawal Symptoms ...... 14

Tips to Help with Withdrawal Symptoms ...... 15

Suggestions for your Diet whilst withdrawing ...... 17

Staying off Tranquillisers and Sleeping Pills ...... 18

Relaxation ...... 19

Breathing Exercise ...... 22

Resources for Further Assistance ...... 23

Introduction

These guidelines will assist people who wish to reduce or come off their minor tranquillisers and/or sleeping pills (benzodiazepines). Benzodiazepines are prescriptions medications used to reduce anxiety or induce sleep. They are only designed to be used short term (for a maximum of 2-4 weeks of regular use), and if used longer term can cause or worsen the symptoms of anxiety and sleeplessness.

Many people can reduce the use of benzodiazepines without too much discomfort, although for others the withdrawal symptoms can be painful and protracted. Unfortunately, there is no way of predicting how severe withdrawal is likely to be for an individual. Generally it is reasonable to assume that people who have taken the drugs for a long time or in very high amounts will experience more severe withdrawal. Also, those who have tried to withdraw previously and experienced difficult withdrawal will be likely to have similar levels of withdrawal symptoms in future.

There are good reasons to stop taking the benzodiazepine group of drugs as it is now well recognised that using these drugs for longer than a few weeks can lead to physical dependency. There are also a number of side effects, including increased depression, memory loss and mood swings. There are side effects that are of particular concern for older people, such as an increased risk of falls, confusion and pseudo-dementia.

All of the guidelines contained in this booklet are based on research, best-practice guidelines nationally and internationally, and guidelines produced by the Australian Medicines Handbook (2010). They are also based on 20 years of experience with clients attending RECONNEXION a service of EACH.

Before you start reducing your benzodiazepines:

Do not stop taking your tablets all at once –

to do so could be dangerous.

 Make sure that the drugs you wish to stop using are in fact benzodiazepines. There is a list of benzodiazepines in the following pages. If you are taking a drug that is not a benzodiazepine, then it may be an antidepressant or antipsychotic medication, in which case the information contained in this booklet will not be relevant. Any decision to reduce your drugs should be done in consultation with your doctor and with their support.

 If you have unresolved personal issues to deal with, then you may feel that it is helpful to see a counsellor while you are going through the reduction or shortly afterwards.

 If you are feeling uncertain about making the first reduction, you might like to practice relaxation and abdominal breathing exercises before your start to cut down your dose. (Examples of relaxation and breathing exercises are included in this booklet)

 Before commencing any reductions, try to get as much support as possible and start at a time that is relatively free of stress.

 If you find that as you reduce, you are finding it increasingly difficult to cope, do not give up. Arrange to get extra support from a counsellor, ideally one trained in benzodiazepine withdrawal support.

It is very important to discuss reducing your pills with your doctor, as many symptoms of benzodiazepine withdrawal can be similar to other illnesses or conditions. You will need a supportive doctor who is able to investigate any concerning symptoms if necessary. Some people have had quite serious conditions while coming off their tablets, which have been mistakenly attributed to withdrawal. A list of withdrawal symptoms is included in this booklet.

List of Benzodiazepines

The following list includes all of the benzodiazepines currently available in Australia. The Australian Medicines handbook recommends that they should be reserved for short-term use only (e.g. 2–4 weeks). If your medication is not on this list, the information contained in the rest of this booklet will not be applicable.

Generic name Brand Name(s) Approximate* Length of Action

Alprazolam Xanax Short Kalma Bromazepam Lexotan Short Clobazam Frisium Long Clonazepam Rivotril Long Paxam Diazepam Valium Valpam Long Antenex Ducene Flunitrazepam Hypnodorm Long Lorazepam Ativan Short

Nitrazepam Alodorm Long Mogadon Oxazepam Serepax Murelax Short Alepam Temazepam Normison Temaze Euhypnos Short Nocturne Temtabs Triazolam Halcion Very short

* Length of action is approximate and varies according to the individual’s metabolism, gender, weight, health of liver and age.

Dose Equivalents

It is sometimes difficult to judge how strong your medication is in comparison to other drugs in the same group. For example, many people think that Xanax*** is not as strong as Valium*** because the dosages sound smaller. This, however, is quite misleading. In fact, a 0.5mg tablet of Xanax / Kalma (Alprazolam) is approximately equivalent to a 5mg Valium (Diazepam) tablet. Below is a table that gives approximate equivalencies to 5mg Diazepam (Valium).

Dose equivalents of commonly available oral benzodiazepines:

Approximate Equivalent Dose Drug Brand Names to Diazepam 5mg*

Alprazolam Xanax,*** Kalma 0.5mg**

Clonazepam Rivotril, Paxam 0.25mg†

Valium, Ducene, Diazepam 5mg Antenex

Lorazepam Ativan 1mg

Nitrazepam Alodorm, Mogadon 5mg

Serepax, Murelax, Oxazepam 15mg Alepam

Euhypnos, Nocturne, Temazepam Normison, Temaze, 10mg Temtabs

* These figures provide a general guide only. There is no exact equivalence, due to widely varying half-lives and receptor binding characteristics. (Source: Therapeutic Guidelines: Psychotropic, Version7, 2013. Therapeutic Guidelines Limited, North Melbourne, Australia.)

** Professor. Heather Ashton’s guidelines suggest an equivalency of 0.25mg may be more realistic.

*** Xanax was taken off the market in Australia in 2014 † Particular care is needed if changing from clonazepam to a different benzodiazepine because there is a wide variety of reported equivalences

NB: If swapping between medications, be aware of the potential for under or over sedation. The aim is to feel about the same taking the Diazepam dose as you did on your previous benzodiazepine dose.

Stabilising and Reducing the Dose

 Stabilising the daily dose  Possible changeover to a long acting benzodiazepine  Stabilising the changed dose  Gradually cutting down the dose

 STEP ONE

Ensure that a regular daily dose of benzodiazepine is evenly spaced throughout the day.

 You may have taken your dose irregularly and will need to think about what would be your average daily dose. If you have been getting your benzodiazepines from only one doctor or only one pharmacy, you can ask them to print off a list of the scripts you have received in the previous three months and calculate your average daily dose.

 If you have only been taking your benzodiazepine at night (e.g. as a sleeping pill), it should remain as a single dose in the evening. As reduction progresses, however, there may be some uncomfortable withdrawal symptoms occurring during the day. If this is the case, your GP may be willing to prescribe a small dose of Diazepam to alleviate the symptoms during the withdrawal process; in which case you would withdraw from the Diazepam last.

 Stabilising the dose may take some time, so try to see it as a process. You have not failed if you have trouble maintaining the average dose. If you find you keep taking more than you planned, write down when this happens and work out five things you will do next time instead of taking the extra pill. Keep this list of five things in a prominent place, as you are likely to ‘forget’. If you continually want to take more, this may be an indicator that perhaps your average daily dose was higher than you realised. You will need to discuss this with your doctor – it is possible that you will need to re-calculate your average dose and stabilise on a slightly higher starting dose.

 STEP TWO

Change over to a long-acting benzodiazepine, such as Diazepam. (N.B. For people over 65 years of age, changing over to a long-acting benzodiazepine is generally not recommended due to the risk of accumulation of the drug in the body.)

 Tranquillisers and sleeping pills (benzodiazepines) are divided into short and long- acting categories as listed on page 5. Check the length of action of the benzodiazepine you wish to cut down.

 If you have been taking a short-acting benzodiazepine (e.g. Oxazepam, Temazepam), changing over to a long-acting benzodiazepine (e.g. Diazepam - Valium) is usually recommended before reducing the dose. The reason for the changeover is that Diazepam stays in the body longer, providing the body with a more stable level of the chemical and minimising withdrawal symptoms between doses.

Diazepam is also easier to physically manage than some of the other benzodiazepines (the tablets are larger and scored) and has the advantage of coming in 5mg or 2mg tablets so allows more flexibility with reduction rates. Discuss this process with your doctor.

Please note if taking a high dosage of a short-acting benzodiazepine (e.g. 4mg of Alprazolam – Xanax/Kalma), it may be more manageable to begin reducing the short- acting benzodiazepine and transfer to a long-acting benzodiazepine at a later point in time due to the potential over sedation of a large quantity of a long acting drug.

 If you have had a negative experience of Diazepam, or do not want to change over for any reason, then simply reduce slowly from the drug you are currently taking.

 If you are transferring to a long-acting benzodiazepine, the dose change should be done one dose at a time, allowing 5 days between each transfer to allow time to acclimatise. Because the equivalencies are approximate, the actual equivalent dose of Diazepam may be difficult to ascertain. Close contact should be kept with your doctor through this time, in case you are taking too much or too little.

Following are two dose transfer examples, however it is important to remember that rates of transfer may vary. Some people are able to change over every 2 days; others need a few weeks between transfers. Maintain each transfer until you feel stable on the changed dose, before transferring the next dose. You may also find you need more or less Diazepam, depending on how you respond. Remember to keep in close contact with your doctor through this time.

Example 1: Dose transfer from a high dosage short-acting benzodiazepine to a long-acting benzodiazepine From an initial dose of 4mg of Alprazolam, and after successfully reduced to 2.25mg Alprazolam, was transferred to Diazepam under advice of GP.

Time: Time: Time: Total Daily Dose Morning Lunch Time Evening Initial Dose 1mg Alprazolam 1mg Alprazolam 2mg Alprazolam 4mg Alprazolam

1.75mg Reduction 1 1mg Alprazolam 1mg Alprazolam 3.75mg Alprazolam Alprazolam

Reduction 2 1mg Alprazolam 1mg Alprazolam 1.5mg Alprazolam 3.5mg Alprazolam

Reduction 3 1mg Alprazolam 1mg Alprazolam 1.25mg Alprazolam 3.25mg Alprazolam

Reduction 4 1mg Alprazolam 1mg Alprazolam 1mg Alprazolam 3mg Alprazolam

Reduction 5 .75mg Alprazolam 1mg Alprazolam 1mg Alprazolam 2.75mg Alprazolam

Reduction 6 .75mg Alprazolam .75mg Alprazolam 1mg Alprazolam 2.5mg Alprazolam

Reduction 7 .75mg Alprazolam .75mg Alprazolam .75mg Alprazolam 2.25mg Alprazolam

0.5mg Alprazolam 0.5mg Alprazolam 0.5mg Alprazolam 1.5mg Alprazolam Transfer 1 2.5mg Diazepam 2.5mg Diazepam 2.5mg Diazepam 7.5mg Diazepam .25mg Alprazolam .25mg Alprazolam .25mg Alprazolam 0.75mg Alprazolam Transfer 2 5mg Diazepam 5mg Diazepam 5mg Diazepam 15mg Diazepam

Final Transfer 7.5mg Diazepam 7.5mg Diazepam 7.5mg Diazepam 22.5mg Diazepam

Example 2: Dose transfer from a low dosage short-acting benzodiazepine to a long-acting benzodiazepine From an initial average daily dose of 1.5mg of Alprazolam (e.g. Xanax or Kalma), transferred to Diazepam (e.g. Valium) under guidance from doctor.

Time: Time: Time: Total Daily Dose Morning Lunch Time Evening

Initial Dose 0.5mg Alprazolam 0.5mg Alprazolam 0.5mg Alprazolam 1.5mg Alprazolam 1mg Alprazolam Transfer 1 5mg Diazepam 0.5mg Alprazolam 0.5mg Alprazolam 5mg Diazepam 0.5mg Alprazolam Transfer 2 5mg Diazepam 5mg Diazepam 0.5mg Alprazolam 10mg Diazepam

Transfer 3 5mg Diazepam 5mg Diazepam 5mg Diazepam 15mg Diazepam

Split Dosage 7.5mg Diazepam Nothing 7.5mg Diazepam 15mg Diazepam

 STEP THREE

Stabilising the changed dose

If you have changed over to a long-acting benzodiazepine, or if you have averaged and spread your dose more evenly through the day, you will need some time to become settled on this new dose. Generally, 1-2 weeks is enough to feel stable and comfortable on the new regime (individuals 65 and over may require up to 4 weeks).

 STEP FOUR

Gradually reducing the dose

Once you are stable:

 Decide which dose you will reduce first (that is, morning, afternoon or evening).

 As a guideline, reduce by about 10% of the total daily dose every 1-2 weeks, with individuals 65 and older taking up to 4 weeks. This 10% reduction rate may become difficult to maintain towards the end of the process as your doses get smaller, and the exact proportion will depend on the physical possibility of cutting the tablets. For example, if you are taking 3 tablets a day, it will be most practical to reduce by ¼ of a tablet, or about 8% of your overall dose.

 Reducing every week or fortnight is the guideline, however this can vary depending on how you find the withdrawal process. Stagger each reduction across the different times: e.g. if you reduce at night one week, then reduce in the morning the following reduction, then the middle of the day for your 3rd reduction.

 If you are having a particularly stressful time in other areas of your life, it may be an idea to reduce less often, or even take a break and remain stable until the worst of the stress has passed.

 If you experience any significant increase in withdrawal symptoms, you may need to slow down or pause the reduction reduce, or consider lowering the amount of the next reduction. Do not, however, increase the amount of tablets you are taking.

 If you have no or minimal withdrawal symptoms, increase the reduction rate and amount slightly.

 Always begin with a small reduction to assess how your withdrawal might look.

NEVER stop ‘Cold Turkey’ e.g. stopping all of your tablets at once. There is the potential for withdrawal seizure following cold turkey withdrawal, and people often find they are overwhelmed by withdrawal symptoms resulting in the need to increase the dose.

Example 3: High Dosage Alprazolam Transfer and Reduction from Diazepam

Time: Time: Time: Total Daily Dose Morning Lunch Time Evening Initial Dose 1mg Alprazolam 1mg Alprazolam 2mg Alprazolam 4mg Alprazolam Reduction 1 1mg Alprazolam 1mg Alprazolam 1.75mg Alprazolam 3.75mg Alprazolam Reduction 2 1mg Alprazolam 1mg Alprazolam 1.5mg Alprazolam 3.5mg Alprazolam Reduction 3 1mg Alprazolam 1mg Alprazolam 1.25mg Alprazolam 3.25mg Alprazolam Reduction 4 1mg Alprazolam 1mg Alprazolam 1mg Alprazolam 3mg Alprazolam Reduction 5 0.75mg Alprazolam 1mg Alprazolam 1mg Alprazolam 2.75mg Alprazolam Reduction 6 0.75mg Alprazolam 0.75mg Alprazolam 1mg Alprazolam 2.5mg Alprazolam Reduction 7 0.75mg Alprazolam 0.75mg Alprazolam 0.75mg Alprazolam 2.25mg Alprazolam 0.5mg Alprazolam 2.00mg Alprazolam Transfer 1 0.75mg Alprazolam 0.75mg Alprazolam 2.5mg Diazepam 2.5mg Diazepam 0.5mg Alprazolam 0.5mg Alprazolam 1.75mg Alprazolam Transfer 2 0.75mg Alprazolam 2.5mg Diazepam 2.5mg Diazepam 5mg Diazepam 0.5mg Alprazolam 0.5mg Alprazolam 0.5mg Alprazolam 1.5mg Alprazolam Transfer 3 2.5mg Diazepam 2.5mg Diazepam 2.5mg Diazepam 7.5mg Diazepam 0.25mg Alprazolam 0.5mg Alprazolam 0.5mg Alprazolam 1.25mg Alprazolam Transfer 4 5mg Diazepam 2.5mg Diazepam 2.5mg Diazepam 10mg Diazepam 0.25mg Alprazolam 0.25mg Alprazolam 0.5mg Alprazolam 1mg Alprazolam Transfer 5 5mg Diazepam 5mg Diazepam 2.5mg Diazepam 12.5mg Diazepam 0.25mg Alprazolam 0.25mg Alprazolam 0.25mg Alprazolam 0.75 Alprazolam Transfer 6 5mg Diazepam 5mg Diazepam 5mg Diazepam 15mg Diazepam 0.25mg Alprazolam 0.25mg Alprazolam 0.5mg Alprazolam Transfer 7 7.5mg Diazepam 5mg Diazepam 5mg Diazepam 17.5mg Diazepam 0.25mg Alprazolam 0.25mg Alprazolam Transfer 8 7.5mg Diazepam 7.5mg Diazepam 5mg Diazepam 20mg Diazepam Transfer 9 7.5mg Diazepam 7.5mg Diazepam 7.5mg Diazepam 22.5mg Diazepam Reduction 8 5mg Diazepam 7.5mg Diazepam 7.5mg Diazepam 20mg Diazepam Reduction 9 5mg Diazepam 5mg Diazepam 7.5mg Diazepam 17.5mg Diazepam Reduction 10 5mg Diazepam 5mg Diazepam 5mg Diazepam 15mg Diazepam Reduction 11 2.5mg Diazepam 5mg Diazepam 5mg Diazepam 12.5mg Diazepam Reduction 12 2.5mg Diazepam 2.5mg Diazepam 5mg Diazepam 10mg Diazepam* Reduction 13 2.5mg Diazepam 5mg Diazepam 7.5mg Diazepam Reduction 14 2mg Diazepam 4mg Diazepam 6mg Diazepam Reduction 15 2mg Diazepam 3mg Diazepam 5 mg Diazepam Reduction 16 2mg Diazepam 2mg Diazepam 4mg Diazepam Reduction 17 1mg Diazepam 2mg Diazepam 3mg Diazepam Reduction 18 1mg Diazepam 1mg Diazepam 2mg Diazepam Reduction 19 1mg Diazepam 1mg Diazepam Reduction 20 Drug free *Prescription for both 5mg & 2mg Diazepam tablets at 10mg Diazepam dosage 11

Example 4: High Dosage Diazepam Reduction (Very Slow)

Time: Time: Time: Total Daily Dose Morning Lunch Time Evening Initial Dose 10mg Diazepam 10mg Diazepam 10mg Diazepam 30mg Diazepam Reduction 1 7.5mg Diazepam 10mg Diazepam 10mg Diazepam 27.5mg Diazepam Reduction 2 7.5mg Diazepam 7.5mg Diazepam 10mg Diazepam 25mg Diazepam Reduction 3 7.5mg Diazepam 7.5mg Diazepam 7.5mg Diazepam 22.5mg Diazepam Reduction 4 5mg Diazepam 7.5mg Diazepam 7.5mg Diazepam 20mg Diazepam Reduction 5 5mg Diazepam 5mg Diazepam 7.5mg Diazepam 17.5mg Diazepam Reduction 6 5mg Diazepam 5mg Diazepam 5mg Diazepam 15mg Diazepam Reduction 7 2.5mg Diazepam 5mg Diazepam 5mg Diazepam 12.5mg Diazepam Reduction 8 2.5mg Diazepam 2.5mg Diazepam 5mg Diazepam 10mg Diazepam* Reduction 9 2mg Diazepam 2mg Diazepam 5mg Diazepam 9mg Diazepam Reduction 10 2mg Diazepam 2mg Diazepam 4mg Diazepam 8mg Diazepam Reduction 11 2mg Diazepam 2mg Diazepam 3mg Diazepam 7mg Diazepam Reduction 12 2mg Diazepam 2mg Diazepam 2mg Diazepam 6mg Diazepam Reduction 13 2mg Diazepam 1mg Diazepam 2mg Diazepam 5mg Diazepam Reduction 14 2mg Diazepam 0.5mg Diazepam 2mg Diazepam 4.5mg Diazepam Reduction 15 2mg Diazepam 2mg Diazepam 4mg Diazepam Reduction 16 1.5mg Diazepam 2mg Diazepam 3.5mg Diazepam Reduction 17 1.5mg Diazepam 1.5mg Diazepam 3mg Diazepam Reduction 18 1mg Diazepam 1.5mg Diazepam 2.5mg Diazepam Reduction 19 1mg Diazepam 1mg Diazepam 2mg Diazepam Reduction 20 0.5mg Diazepam 1mg Diazepam 1.5mg Diazepam Reduction 21 0.5mg Diazepam 0.5mg Diazepam 1mg Diazepam Reduction 22 0.5mg Diazepam 0.5mg Diazepam Reduction 23 Drug Free *Prescription for both 5mg & 2mg Diazepam tablets at 10mg Diazepam Dosage

Benzodiazepine Withdrawal Symptoms

Common Withdrawal Symptoms Less Common Withdrawal Symptoms

 Abdominal pains & cramps  Aching jaw

 Agoraphobia  Craving for sweet food

 Anxiety  Constipation

 Breathing difficulties  Depersonalisation (a feeling of not knowing who

 Blurred vision you are)

 Changes in perception (faces distorting,  Diarrhoea inanimate objects, surfaces or ground moving)  Difficulty swallowing

 Depression  Hallucinations (auditory and visual)

 Dizziness  Hyperactivity

 Extreme lethargy  Hypersensitivity to sound

 Fears (uncharacteristic)  Incontinence or urinary frequency & urgency

 Feelings of unreality  Loss or change in appetite

 Flu-like symptoms  Loss or changes in taste (metallic taste in mouth)

 Heavy limbs  Menstrual problems (painful periods, irregular

 Heart palpitations periods or cessation of periods)

 Hypersensitivity to light  Morbid thoughts

 Indigestion  Numbness in any part of the body

  Insomnia Outbursts of rage & aggression

  Irritability Paranoia

  Lack of concentration Painful scalp

  Lack of coordination/balance Persistent, unpleasant memories

  Loss of memory Pins & needles

 Muscular aches & pains  Rapid changes in body temperature

 Nausea  Sexual problems (changes in libido)

 Nightmares  Skin problems (dryness, itchiness, rashes, slow healing, boils)  Panic attacks  Sore mouth & tongue (ulcers, cracked lips, cold  Rapid mood changes (crying & then laughing) sores)  Restlessness  Speech difficulties  Severe headaches  Suicidal thoughts  Shaking  Tinnitus (buzzing or ringing in the ears)  Seeing spots and Sore eyes  Unusually emotionally sensitive (e.g. unable to  Sweating watch the news on television)  Tightness in the chest  Vomiting  Tightness in or around the head  Weight loss or gain

Rare Withdrawal Symptoms

 Blackouts (less rare on large doses)  Menorrhagia (cessation/interruption to

 Bleeding from the nose menstrual cycle)

  Burning along the spine Rectal bleeding

  Burning sensation around the mouth Sinus pain

  Discharge from the breasts Seizures (fits)

 Hair falling out  Sensitive or painful teeth

 Haemorrhoids  Swollen breasts

 Hypersensitivity to touch 13

Management of Withdrawal Symptoms

 Withdrawal symptoms vary in severity from person to person. Symptoms appear to be related more to the length of time the person has been using benzodiazepines than to the amount taken. For example, a person can experience quite distressing symptoms on as little as 1.5mg Alprazolam taken daily for 12 months or more.

 Withdrawal symptoms can be erratic, and in some people have been known to last for a number of months, or even up to a year after ceasing all benzodiazepines. It is not uncommon for people who have been managing well for a period of time to have a sudden ‘bout’ of withdrawal symptoms.

 Most physical withdrawal can be managed by treating the symptoms with rest, heat or cold, or relaxation. Recent research is encouraging in demonstrating that relaxation techniques help to reduce the symptoms of withdrawal. The psychological symptoms are best managed by distraction, relaxation, mindfulness meditation, reassurance and, occasionally, drug treatment (see below for further detail).

If you are worried that your symptoms might be some other physical problem, make sure to follow these up with your doctor.

Use of Other Medications in Withdrawal

Unfortunately there is no substitute medication for benzodiazepines (i.e. as there is methadone/suboxone for heroin). Sometimes GPs will recommend analgesics or antiemetic (anti-nausea) medications to relieve symptoms, however, people typically report that these medications are unhelpful, and do not reduce the severity or frequency of symptoms.

Although most clients find they can cope with intermittent depression in withdrawal with support, some people experience severe prolonged depression in withdrawal and the use of anti-depressants may be helpful.

Zolpidem (Stilnox) and Zopiclone (Imovane) are non-benzodiazepine sleeping tablets. They are not appropriate as a substitute sedative for people trying to come off benzodiazepines. They are both designed for short term use only, with long term use creating a risk of dependency and withdrawal similar to the long term use of benzodiazepines.

Withdrawal can often cause physical pain; however, many people report that the pain is not relieved by analgesics. Nevertheless, you should certainly try analgesics if you are in pain, but ensure that you monitor your use of analgesics and their effectiveness (i.e. if two paracetamol tablets don't help there is no point in taking four). It is also worth trying alternative methods of pain relief (e.g. rest, hot/cold packs, massage, relaxation and some forms of exercise in consultation with an appropriate practitioner). 14

Tips to Help with Withdrawal Symptoms

TAKING CARE WITH DIET Many people experience either an increase in appetite or loss of appetite in withdrawal. Make the effort to maintain a healthy diet. Ask for help if necessary, as sometimes you may feel too sick to prepare food. Diet can be an important element in maintaining your energy levels and ability to cope with withdrawal. Cut down or eliminate stimulants such as coffee, tea, cola drinks, energy drinks, chocolate and nicotine from your diet. Often small meals eaten more frequently can be less stressful on the digestive system than large meals.

CUTTING DOWN OR STOPPING ALCOHOL Try to be abstinent whilst coming off your pills and during the withdrawal period. People have reported that if they do drink during withdrawal their symptoms worsen; also there is a danger of insidiously increasing your alcohol intake as you reduce your benzodiazepine intake. As alcohol takes effect in the brain in a similar way to benzodiazepines, there is the chance that you may begin to compensate for a lowering benzo dose by increasing your alcohol consumption.

EXERCISING Gentle exercise such as walking or swimming should be undertaken daily. Agoraphobia is a common withdrawal symptom so try to get out for a walk if possible. If you are used to being very active in sport and/or it is your preferred method of relaxation, then continue, but you need to be aware that muscle spasm is common in withdrawal and you may feel exceptionally sore after a day's sport. You may also notice that your performance is not as good as you would expect.

KEEPING A DIARY Making notes in a daily diary can help to give you a sense of achievement and is also useful in recording strategies that have helped you cope with withdrawal. A diary will give you an objective measure of your progress over time, as memory can be quite effected throughout the withdrawal process. Moreover, it can also be useful for expressing and working through emotional issues.

PRACTICING A RELAXATION OR MEDITATION Almost all people experience raised anxiety levels as part of the withdrawal syndrome and, of course, many people were originally prescribed benzodiazepines for anxiety. Therefore it is useful to learn to use a relaxation/meditation technique in order to manage your anxiety. A simple Yoga deep breathing technique or counting technique is helpful for controlling bouts of anxiety and for control of panics attacks in withdrawal, and a few techniques are offered towards the end of this workbook. 15

SUPPORT RECONNEXION provides a telephone support and information service for people withdrawing from benzodiazepines. All the RECONNEXION telephone support workers are comprehensively trained in benzodiazepine dependence. Clients often find it particularly reassuring to be able to talk with these people, as do many family members for support and information. RECONNEXION can be contacted on 03 9809 8200 or 1300 273 266 or via the website www.reconnexion.org.au

COUNSELLING Some withdrawal is straight-forward and requires no more than knowledge of a reducing regime and some information and support. You may find, however, that you need more intensive counselling either to enable you to cope effectively without pills or because of unresolved issues to do with your use of benzodiazepines, or both. Counselling is available at RECONNEXION. Alternatively, ask your doctor for a good counselling service, contact your local Community Health Service or contact your nearest Alcohol and Drug Counselling Service. Our benzodiazepine counsellors offer secondary consults and are happy to speak with any health practitioners involved in your care.

Suggestions for your Diet during Withdrawal

In withdrawal, it is particularly important to eat well and maintain blood sugar levels.

Eat plenty of complex carbohydrates:  Breads, rice, cereals, pasta  Potatoes, sweet potato, sweet corn, parsnip, carrots  Pulses – dried beans, peas and lentils  Fruit  Milk and yoghurt.

Eat less fat and sugar:  Eat lean red meat  Low fat milk, skim milk dairy products  Reduce or limit eating: o Fried fast foods o Pies, pasties, cakes, muffins and biscuits o Cream, butter, margarine, cooking and salad oils o Chocolates and snack foods.

Eat plenty of fresh fruit and vegetables:  Eat plenty of leafy green vegetables such as spinach, lettuce, chard, and kale  Supplement your diet with health snacks such as carrot and celery  Low sugar fruits such as berries, grapefruit, papaya, melons  Avoid sugary fruit juices

Eat regularly Regular and smaller meals are preferable to two or three big meals a day. This will help to stabilise your blood sugar levels and avoids fluctuations in your body’s fuel source. Withdrawal is characterised by ups and downs in symptoms, and doing anything to help your body feel stable, by way of routine, will help the process greatly.

Staying off Tranquilisers and Sleeping Pills

Some people feel such an aversion to the benzodiazepines that they have been taking, and feel so much better once they have come off the drugs, that they have no trouble staying off the pills and no desire ever to take another one. For other people, the habit of taking a benzodiazepine to help them cope or to get to sleep is a hard one to break, and the temptation is often there to take another pill. During the cutting down or reduction of the drugs, sometimes the withdrawal symptoms are so bad that you take an extra tablet or two. Although this is not advisable, it is not the end of the world and should be seen as part of the process towards coming off the drugs, and not as a reason to give up your program of cutting down.

Some things that are helpful to stay off the pills include:

New coping skills: As you have been coming off the pills you will have started to learn different ways of coping without using the benzodiazepines. This may have been a subtle process or you may be aware of having to struggle to do things differently. Remind yourself that you have proved you can cope without the pills. Write down five things that you will always do before allowing yourself to take a pill. You may also find certain courses helpful, such as cognitive behavioural therapy, mindfulness meditation, assertiveness, stress management or self-esteem groups. Many Community Health Services and some hospitals run these courses at reasonable cost. Reconnexion offers mindfulness meditation courses.

Go slowly when starting to drink alcohol: Make sure you feel really well before gradually re- introducing a social drink into your life. Remember, alcohol has been known to worsen the symptoms of withdrawal

Practice relaxation daily: If you find you let it slip, then at least be aware of having your relaxation training as a resource to fall back on whenever you feel stressed or are not sleeping.

Talk to someone: You may have a partner or friend who can help you over the tough times or who may have some good ideas for coping. You may also want to call or see the doctor who has been helping you through the reduction process. Alternatively you can call RECONNEXION on 03 9809 8200 or 1300 273 266. The RECONNEXION telephone support service in Melbourne is available Monday to Friday 9am-5pm. Most states in Australia also have a general Alcohol and Drug Telephone Service that can provide advice and support, and they are generally available 24 hours a day..

Take it easy: You will be vulnerable to stress for a period of time once you are through the worst of the withdrawal. Don’t expect to immediately resume your former lifestyle, allow yourself time to do your relaxation, exercise and other activities that you enjoy.

Relaxation

Relaxation is a state of deep rest for the mind and body. This state is not achievable through normal rest and sleep. It is not the same sort of relaxation that we talk about when we talk about ‘relaxing in front of the television’.

In deep relaxation, the body responds by relaxing the muscles, and lowering blood pressure and the heart rate. The mind becomes calm and peaceful.

As tension accumulates through the hundred and one things that may happen through the day, so relaxation is the means of letting go of that tension.

Tension, stress or anxiety for anything more than a short period of time can have negative effects on the body. Muscle stiffness and soreness, abdominal pain, overactive bowel and bladder – these are just some of the possible effects.

Relaxation is a great tool for a healthy mind and body.

There are many different types of relaxation techniques. All of the techniques have the same goal – to release the tension in the body and promote a calm peaceful experience. It doesn’t matter which technique you use, as long as it works for you and you enjoy doing it. Having experienced what deep relaxation feels like, you will want to do it again and again.

Some relaxation techniques involve: tightening and relaxing the muscles throughout your body (either all at once or progressively one muscle group at a time); relaxing all parts of the body by placing your attention on each area and focussing on relaxing each muscle group; visualising or imagining a peaceful scene, giving the scene lots of detail and involving all your senses (what would the scene smell like, sound like, feel like etc); or repeating a mantra (a word or a phrase). Examples of two forms of relaxation are included in the following pages. Examples of breathing techniques are also provided.

Relaxation should ideally be practiced daily, preferably around the same time and in the same place.

Visual Imagery Relaxation

To assist you to relax, you may like to picture or visualise a peaceful scene which you find pleasant and calming. Some examples of scenes that people commonly choose are: lying on the warm sand at a beach, walking through a rain forest, sitting on a warm rock by a river or stream, lying in a grassy meadow, or walking through a beautiful garden. It is important that you choose a scene that you can imagine and relate to, and that has pleasant associations for you.

Once you have chosen a scene, close your eyes and picture the scene in detail. Once you are imagining your peaceful scene, focus on your senses: for example, the warmth of the sun on your skin, the soft sound of the waves or breeze, the refreshing colours of the sky or the trees, the scent of the flowers or water. Concentrate on creating a really vivid and complete image of your scene.

After a while you will feel calmer and ready to leave your scene. Imagine yourself getting up, stretching and walking away. Then wriggle your toes, stretch your hands and arms and open your eyes. If you have been lying down, sit up slowly as your blood pressure will have lowered while you’ve been relaxed and you may be dizzy for a moment if you sit or stand too quickly.

Benson’s Relaxation Response

Research indicates that if your practise this technique for 10 minutes a day over 10 consecutive days, it will become a skill. Try and practise around the same time each day. The technique can be used to help you sleep, but this should not be your daily practise. (The key points are highlighted in bold.)

1. Sit or lie comfortably in an open, relaxed posture. Focus on relaxing your jaw, shoulders and fingers.

2. Notice how you are breathing. Focus completely on the pathway of your breath moving in and out of your body. Use self-talk to maintain this focus.

3. Breathe from your stomach as a natural rhythm. As you breathe in, your stomach rises (fills up with air). As you breathe our, your stomach falls (push air out of the body). Continue to breathe in this way for 3-5 minutes.

4. When you begin to find a rhythm, on the outward breath quietly say to yourself ‘RELAX’. Continue to breathe in this way for a few more minutes.

5. For 30 second bursts begin to focus on an image that moves in and out with the rhythm of your breath (e.g. curtains in a breeze, waves on a beach, swings). As you breathe in (stomach rising) the image moves towards you. As you breathe out (stomach falls, ‘RELAX’), the image moves away from you.

6. Try to make the image as vivid as possible, using as many senses as you can (sight, sound, smell, taste and touch).

7. After 30 seconds bring your focus back to your breathing. Begin the whole process again.

Breathing Exercises

Abdominal Breathing Technique – Introduction

A simple abdominal breathing technique is an invaluable aid in combating anxiety. Once the technique has been mastered, it can be practiced anywhere – waiting in a queue, while stopped at a traffic light, waiting for a job interview, or at a social gathering. There are many different abdominal breathing techniques. The technique offered here is only one variation.

It is important to practice the technique when you are not feeling anxious, until you become skilled at this method and can easily slip into this style of breathing. This ensures that when you use the technique in an anxiety situation, you will be comfortable with it and will not need to worry about whether you are doing it correctly.

Why use a breathing technique?

When we become anxious, our breathing rate increases and often become quite shallow. The abdominal breathing technique slows our breathing and allows the oxygen to fill the lower parts of the lungs. This technique decreases the escalation of our anxiety or feelings of panic. By breathing slowly and deeply the unpleasant physical symptoms of anxiety are reduced. This form of breathing also has a calming effect on the mind. It is difficult for the mind to concentrate on two things at once, so while the mind is concentrating on the abdominal breathing technique it is less able to focus on the anxious thoughts.

Abdominal Breathing – the Technique

Practice while sitting in a comfortable chair or lying on your back on the floor with your knees bent. Close your eyes (although you can leave them open if you prefer). Rest your hands gently on your stomach, so you can feel it moving as you breathe.

 Push your abdominal muscles out. As you push them out, breathe in deeply through your nose.  Tuck your abdominal muscles in, and breathe out slowly through your nose or mouth.  Repeat this process for approximately 2-5 minutes.

In other words, as you breathe in, your tummy should rise and fill beneath your hands. As you breathe out, your tummy should slowly deflate.

The aim of this breathing technique is to deepen each breath so that the lungs are really expanded, and also to breathe more slowly each time. Each step should move smoothly into the next one. The general aim of abdominal breathing is to slow down the body and the anxiety. It can help to start this process by exhaling one long breath out before starting the technique.

Resources for Further Assistance

Information about other agencies in Victoria providing benzodiazepine withdrawal support can be obtained by ringing RECONNEXION or DIRECT LINE. RECONNEXION 1939 Malvern Road, Malvern East, Vic 3145

 +61(03) 9809 8200 1300 273 266 email: info@reconnexion .org.au web: www.reconnexion.org.au DIRECT LINE  1800 888 236

RECONNEXION also provides specialist counselling for adults, children and young people experiencing anxiety disorders or depression. Printed information about benzodiazepines can be obtained from RECONNEXION or the AUSTRALIAN DRUG FOUNDATION.

ADDITIONAL RESOURCES AVAILABLE FROM RECONNEXION

Relaxation Tapes/CD’s "Relaxation with Gwenda Cannard". This cd provides two distinct relaxation exercises: a progressive muscle relaxation and a creative visualisation exercise. Both tracks have original lyre music by John Billings.

Better Sleep Booklet by Gwenda Cannard This book provides a comprehensive description of normal sleep and different sleep problems, and provides practical tips and strategies to apply for each different problem.

Better Sleep DVD Reconnexion’s DVD, BETTER SLEEP: HOW TO OVERCOME SLEEPING PROBLEMS covers the symptoms of sleep disorders, who is at risk of developing them, and how they are diagnosed and treated. Translated into 6 languages

Sweet Dreams How to reduce the use of sleeping pills and tranquillisers in residential aged care facilities. One page information sheet on benzodiazepines – this is has also been translated into 21 languages.

Other useful resources: Living with It: A survivor’s Guide to Panic Attacks by Bev Aisbett Power over Panic: Freedom from panic/anxiety related disorders by Bronwyn Fox